Innovations in Water and Sanitation Helping people living with HIV to access better water and sanitation facilities Why consider water and sanitation in homebased care for people living with HIV? Today, more than 33 million people around the world are living with HIV and AIDS. One key strategy in mitigating the effects of this epidemic is the provision of community homebased care given to infected clients by family members and health workers. According to the World Health Organization (WHO), the goal of such care is “to provide hope through high-quality and appropriate care that helps ill people and families to maintain their independence and achieve the best possible quality of life.” A healthy environment is crucial for maintaining the quality of life of people living with HIV and for the success of homebased care. WHO estimates that 85 to 90 percent of diarrheal illnesses in developing countries can be attributed to unsafe water and inadequate sanitation and hygiene practices. Safe hygiene practices that can reduce the prevalence of diarrheal disease include handwashing with soap, treatment and safe storage of water, and safe feces disposal. Proper care requires not only safe drinking water but also larger quantities of water for hygiene and sanitation purposes. In addition, because of physical limitations caused by HIV and AIDS, the design of water and sanitation facilities greatly influences effective access to these services. Unfortunately, water and sanitation services are extremely limited in many of the countries most affected by the HIV and AIDS pandemic.
Worker in Kerala, India. Photo by David Snyder.
AIDS education in Angola. Photo by David Snyder.
This lack of access to services can have the following detrimental effects: •
Opportunistic infections, resulting from a combination of environmental pathogens and the suppression of immune functions in PLHIV, can hasten the progression of HIV to AIDS (Chaisson et al 1998; Seage et al 2002). The frequency of these infections is closely tied to the level of water and sanitation services available to households affected by the disease as well as the hygiene practices of household members.
Mothers infected with HIV can transmit the virus to their children through breastmilk. WHO recommends exclusive breastfeeding for HIV-infected women for the baby’s first six months of life. This requires both access to adequate quantities of potable water and hygienic preparation (such as the proper washing of hands and food, and the proper washing and storage of the preparation and eating utensils) in order to prevent water-related diarrheal disease.
Water and sanitation services which are located in close proximity to HIV-affected households can have important labor saving effects, reducing the burden of caregiving and allowing more time for other activities, including school and income generation.
Access to water for productive purposes can improve household food security by allowing for food production and participation in certain income generating activities. Additionally, potable drinking water is often used to soften foods, making them more palatable for the chronically ill.
Overall, the success of HBC is dependent upon access to potable water, access to sanitation facilities that are appropriate for use by the chronically ill, knowledge of water treatment techniques and good hygiene practices. In addition, it is crucial that these improved hygiene practices be successfully adopted by other household members.
Households caring for PLHIV with advanced illness may also require a greater quantity of water than other households for medicines, bathing and laundry. This adds to the existing burden on caregivers to collect water.
What is CRS doing in WASH to help people living with HIV? In October 2007, CRS, USAID and WHO held a workshop in Malawi on strategies for the integration of water, sanitation and hygiene into HIV/AIDS home-based care. The workshop
reviewed lessons learned from country studies commissioned by WHO in 2006, developed policy recommendations for Malawi, and outlined a strategic approach for the international community. A subsequent pilot program to improve WASH behaviors and outcomes within ongoing HIV programming was carried out in Ntcheu District of Malawi. The project promoted six target behaviors including: hand washing at the critical times, appropriate hand washing technique, point-of-use water treatment, safe water storage, consistent latrine use and safe disposal of feces. An evaluation in March 2009 indicated that the project interventions were effective in achieving significant improvements in the targeted behaviors. The success was due to the ability by community volunteers to negotiate small, do-able actions, the addition of complementary interventions to improve access to basic services, and the support of government officials and traditional leaders. CRS is now helping country programs to modify their existing WASH activities to meet the specific needs of people living with HIV. Modifications to current water supply activities include considerations for water access, water transport, water scarcity, water treatment and storage and water quality. Regarding sanitation, modifications to sanitation access, cleanliness, latrine designs and construction technologies and supporting products and materials are detailed. Also included is a strong emphasis on hygiene practices, especially regarding hygiene in HBC. In addition, a self-paced training module on WASH considerations in HBC for PLHIV is also being developed.
Looking ahead CRS and partner staff are the primary audience for the guidance materials and training module under development. Participants need not be currently involved in WASH programming in HBC for PLHIV, but there should be an interest in improving their planning capabilities within their respective country operations. Ideally, participants would include program managers, heads of programming, regional or country technical advisors, or other managers who are actively involved in the management and design of WASH and/or HIV programs. One challenge is to help staff become comfortable in applying this knowledge to the two sectors. In-depth technical knowledge of WASH or HBC for PLHIV is not necessary to be effective. The main barriers to the expansion of WASH in HBC for PLHIV programs are (a) traditional separation of the WASH and HIV/AIDS sectors, (b) minimal examples of integrated WASH and HIV/AIDS programs, and (c) reluctance of donors to promote these programs. CRS intends to overcome these barriers through awareness raising, staff education and training, and field-based evidence.
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Helping people living with HIV to access better water and sanitation facilities